Mental Health and Health-Related Quality of Life After Firearm Injury: A Preliminary Descriptive Study
Authors: Sydney C. Timmer-Murillo, Sarah J.H. Melin, Carissa W. Tomas, Timothy J. Geier, Amber Brandolino, Andrew T. Schramm, Christine L. Larson, Terri A. deRoon-Cassini
Journal: Annals of Internal Medicine (2023)

LettersJuly 2023Mental Health and Health-Related Quality of Life After Firearm Injury: A Preliminary Descriptive StudyFREESydney C. Timmer-Murillo, PhD, Sarah J.H. Melin, MPH, Carissa W. Tomas, PhD, Timothy J. Geier, PhD, Amber Brandolino, MS, Andrew T. Schramm, PhD, Christine L. Larson, PhD, Terri A. deRoon-Cassini, PhDSydney C. Timmer-Murillo, PhDDivision of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, Sarah J.H. Melin, MPHMedical College of Wisconsin, Milwaukee, Wisconsin, Carissa W. Tomas, PhDDivision of Epidemiology & Social Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin, Timothy J. Geier, PhDDivision of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, Amber Brandolino, MSDivision of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, and Division of Data Surveillance & Informatics, Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, Wisconsin, Andrew T. Schramm, PhDDivision of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, Christine L. Larson, PhDDepartment of Psychology, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, Terri A. deRoon-Cassini, PhDDivision of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, and Division of Data Surveillance & Informatics, Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, WisconsinAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M23-0309 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Background: Firearm injury is a public health crisis in the United States (1). Organizations have called for the consideration of long-term consequences of firearm violence, particularly for those directly impacted. Interpersonal firearm violence survivors report significantly worse physical health and functioning compared with the general population and other mechanisms of traumatic injury (1). Furthermore, firearm violence impacts the mental health of survivors and communities. Yet, there is limited work examining self-reported mental and physical health consequences of firearm violence for survivors acutely after injury, thwarting health care systems' ability to comprehensively intervene.Objective: To describe the mental health symptoms and health-related quality of life of firearm injury survivors 6 months after injury.Methods: A convenience sample of 87 adults was recruited from the trauma service of a level 1 trauma center in a midwestern, mid-sized city. Data were pooled from 2 studies occurring at the same center between the years of 2014 to 2016 and 2017 to 2021; both studies examined psychological and biological outcomes of traumatic injury (2). Participants were recruited in the emergency department or during hospitalization. Inclusion criteria were: 1) being 18 years of age or older, 2) having a Glasgow Coma Scale score of at least 13 on arrival, 3) having an unintentional suicidal self-injury, and 4) communicating in English. Exclusion criteria were: 1) experiencing loss of consciousness greater than 30 minutes, 2) experiencing posttraumatic amnesia for more than 24 hours, or 3) being in police custody. Although both studies recruited participants with all mechanisms of injury, the current investigation presents data on patients with interpersonal firearm-related injuries. Baseline sessions occurred up to 1 month postinjury and follow-up approximately 6 months after injury. After consent, participants completed measures on posttraumatic stress disorder (PTSD; PTSD Symptom Checklist for DSM-5); depression, anxiety, and stress (Depression, Anxiety, and Stress Scale [DASS-21]); and physical health-related quality of life (Short Form 12). Studies were approved by the Medical College of Wisconsin institutional review board and were funded by the National Institute of Mental Health. The funding organization was not involved in study design, data collection, or analyses.Findings: The Table provides demographic characteristics and outcome variables at baseline and 6 months. At baseline, patients exhibited symptoms of PTSD with a mean score of 27.15 (SD, 19.19), but symptoms were more severe at 6 months at a mean score of 38.66 (SD, 19.91). The PTSD mean score was above the recommended diagnostic cutoff of 34 for PTSD after interpersonal trauma and was higher than previous injury samples (3). Using interpretation guidelines from DASS-21, anxiety was "mild" at baseline with a mean score of 9.28 (SD, 9.23) and "moderate" at 6 months with a mean score of 11.20 (SD, 11.17). Depressive symptoms were in the "normal" range at baseline with a mean score of 7.25 (SD, 8.91), and higher at 6 months, nearing the cutoff to mild range at a mean score of 9.56 (SD, 10.87). Patients reported normal stress levels at a mean score of 9.52 (SD, 9.31) at baseline. Although reported stress was higher at 6 months with a mean score of 12.93 (SD, 11.29), it was still within the normal range. Patients' health-related quality of life was poor at baseline at a mean score of 30.48 (SD, 13.94), remained poor at 6 months with a mean score of 30.45 (SD, 19.22), and was well below scores reported in previous studies of both injury populations and the general population (4). The Figure shows changes in outcome measures from baseline to 6 months.Table. Sample Demographics, and Mental Health and Health-Related Quality-of-Life Descriptive StatisticsCharacteristicDescriptive StatisticRangeSex, n (%) Female77 (88.5)– Male10 (11.5)–Race, n (%) Asian1 (1.1)– Black/African American69 (79.3)– Hispanic/Latinx11 (12.6)– White/European American6 (6.9)–Psychiatric history,* n (%) Yes36 (41.4)– No50 (57.5)–Mean age (SD), y32.96 (10.06)18–57Mean Injury Severity Score (SD)13.12 (8.49)1–43Mean PCL-5–PTSD score† (SD) Baseline (n = 87)27.15 (19.19)1–72 6 mo (n = 41)38.66 (19.91)2–73Mean DASS-21–Anxiety score† (SD) Baseline (n = 87)9.29 (9.23)0–42 6 mo (n = 41)11.20 (11.17)0–42Mean DASS-21–Depression score† (SD) Baseline (n = 87)7.25 (8.91)0–42 6 mo (n = 41)9.56 (10.87)0–42Mean DASS-21–Stress score† (SD) Baseline (n = 87)9.52 (9.31)0–38 6 mo (n = 41)12.93 (11.29)0–42Mean SF-12 Physical Health score‡ (SD) Baseline (n = 87)30.48 (13.94)5.17–55.48 6 mo (n = 41)30.45 (19.22)0–60.73DASS-21 = Depression, Anxiety, Stress Scale; PCL-5 = PTSD Checklist for DSM-5, measure of PTSD symptom severity; PTSD = posttraumatic stress disorder; SF-12 = Short Form 12, for physical health.* One participant declined to answer.† Higher scores are indicative of worse symptoms for PTSD, Depression, Anxiety, and Stress.‡ Lower scores are indicative of poorer health for Physical Health. Download table Table. Sample Demographics, and Mental Health and Health-Related Quality-of-Life Descriptive StatisticsFigure. Mental and physical health outcome variables across time.Error bars depict SE. DASS-21 = Depression, Anxiety, and Stress Scale; PCL-5 = PTSD Checklist for DSM-5, measure of PTSD symptom severity; PTSD = posttraumatic stress disorder; SF-12 = Short Form 12, for physical health.* Lower SF-12 scores correspond to poorer health. General population average from Haider et al (4). Download figure Download PowerPoint Discussion: The need to understand the physical and mental health consequences of firearm injury in the United States is vital. In this preliminary descriptive study, firearm injury survivors reported poor PTSD acutely after the injury that persisted at 6 months. Furthermore, these patients endorse poor physical health–related quality of life across time, with values worse than previously studied injury samples (4). Medical advancements have increased the survivability of firearm injury, though survivors still carry the burden of injury as the mental and physical health outcomes seem poorer relative to the general population and those who have sustained other traumatic injuries (1, 4). These findings must be considered within the context of limitations including the small convenience sample, relatively short follow-up, and lack of data on preinjury mental health comorbidity. However, this preliminary study highlights the needs to better understand and manage the mental health consequences of firearm injury. Early screening and comprehensive care may improve outcomes in this at-risk population.References1. Timmer-Murillo SC, Schroeder ME, Trevino C, et al. Comprehensive framework of firearm violence survivor care: a review. JAMA Surg. 2023. [PMID: 36947025] doi:10.1001/jamasurg.2022.8149 CrossrefMedlineGoogle Scholar2. deRoon-Cassini TA, Bergner CL, Chesney SA, et al. Circulating endocannabinoids and genetic polymorphisms as predictors of posttraumatic stress disorder symptom severity: heterogeneity in a community-based cohort. Transl Psychiatry. 2022;12:48. [PMID: 35105857] doi:10.1038/s41398-022-01808-1 CrossrefMedlineGoogle Scholar3. Geier TJ, Hunt JC, Nelson LD, et al. Detecting PTSD in a traumatically injured population: The diagnostic utility of the PTSD Checklist for DSM-5. Depress Anxiety. 2019;36:170-178. [PMID: 30597679] doi:10.1002/da.22873 CrossrefMedlineGoogle Scholar4. Haider AH, Herrera-Escobar JP, Al Rafai SS, et al. Factors associated with long-term outcomes after injury: results of the functional outcomes and recovery after trauma emergencies (FORTE) multicenter cohort study. Ann Surg. 2020;271:1165-1173. [PMID: 30550382] doi:10.1097/SLA.0000000000003101 CrossrefMedlineGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: Sydney C. Timmer-Murillo, PhD; Sarah J.H. Melin, MPH; Carissa W. Tomas, PhD; Timothy J. Geier, PhD; Amber Brandolino, MS; Andrew T. Schramm, PhD; Christine L. Larson, PhD; Terri A. deRoon-Cassini, PhDAffiliations: Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, WisconsinMedical College of Wisconsin, Milwaukee, WisconsinDivision of Epidemiology & Social Sciences, Medical College of Wisconsin, Milwaukee, WisconsinDivision of Trauma and Acute Care Surgery, Medical College of Wisconsin, Milwaukee, and Division of Data Surveillance & Informatics, Comprehensive Injury Center, Medical College of Wisconsin, Milwaukee, WisconsinDepartment of Psychology, University of Wisconsin-Milwaukee, Milwaukee, WisconsinGrant Support: By National Institute of Mental Health (NIMH) grants R21MH102838 and R56MH116656-01A1 (both to Dr. deRoon-Cassini).Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M23-0309.Reproducible Research Statement: Study protocol: The protocol is available from the senior author, Dr. deRoon-Cassini, on reasonable request (e-mail, tcassini@mcw.edu). Statistical code: Not applicable due to the study's descriptive nature. Data set: The data that support the findings of this study have been submitted and stored with NIMH in the Research Domain Criteria Database (RDoCdb) repository as a requirement of receiving funding and are available from the senior author, Dr. deRoon-Cassini, on reasonable request (e-mail, tcassini@mcw.edu).Corresponding Author: Sydney Timmer-Murillo, PhD, Division of Trauma and Acute Care Surgery, Medical College of Wisconsin, 8701 West Watertown Plank Road, Milwaukee, WI 53226; e-mail: stimmer@mcw.edu.This article was published at Annals.org on 23 May 2023. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetails Metrics July 2023Volume 176, Issue 7Page: 1010-1012KeywordsAnxietyDepressionFirearm injuriesPreventive medicinePsychiatry and mental healthQuality of lifeTraumatic injury ePublished: 23 May 2023 Issue Published: July 2023 Copyright & PermissionsCopyright © 2023 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...